Subdural hemorrhage: Difference between revisions
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==Background== | ==Background== | ||
[[File:Meninges-en.svg|thumb|Anatomy of the meninges]] | |||
*Can present as acute (<14 days) and chronic (>14 days) | *Can present as acute (<14 days) and chronic (>14 days) | ||
*Both types are caused by sudden acceleration-deceleration of the brain with resultant shearing of the bridging veins. | *Both types are caused by sudden acceleration-deceleration of the brain with resultant shearing of the bridging veins. | ||
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*Patients with extreme atrophy are at increased risk (elderly, alcoholics) | *Patients with extreme atrophy are at increased risk (elderly, alcoholics) | ||
**Patients less than 2 years old are also at increased risk | **Patients less than 2 years old are also at increased risk | ||
*SDH are often associated with other brain injuries | *SDH are often associated with other [[TBI|brain injuries]] | ||
==Clinical Features== | ==Clinical Features== | ||
*Patients with acute SDH generally will present unconscious after a severe trauma | *Patients with acute SDH generally will present unconscious after a severe [[head trauma|trauma]] | ||
*Patients with chronic SDH generally present with altered mental status or vague complaints | *Patients with chronic SDH generally present with [[altered mental status]] or vague complaints | ||
*High index of suspicion warranted in the aforementioned groups of patients at increased risk with any history of head trauma regardless of severity | *High index of suspicion warranted in the aforementioned groups of patients at increased risk with any history of head trauma regardless of severity | ||
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[[File:Subduralandherniation.png|thumb|Large left-sided frontal-parietal subdural hematoma with associated midline shift.]] | [[File:Subduralandherniation.png|thumb|Large left-sided frontal-parietal subdural hematoma with associated midline shift.]] | ||
{{Head trauma workup}} | {{Head trauma workup}} | ||
*Noncontrast CT | *Noncontrast [[head CT|CT]] brain is the gold standard | ||
**Acute SDH will show as a hyperdense (white) collection with a crescent-shaped appearance | **Acute SDH will show as a hyperdense (white) collection with a crescent-shaped appearance | ||
**Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape | **Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape | ||
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*Emergent neurosurgical evacuation | *Emergent neurosurgical evacuation | ||
**Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)<ref>Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24</ref> <ref>Evans JA, et al. A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury. 2015 Jan;46(91):76-9</ref> | **Operative intervention generally for patients with focal findings, >10mm hematoma, midline shift > 5mm, signs of increased intracranial pressure (ICP)<ref>Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24</ref> <ref>Evans JA, et al. A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury. 2015 Jan;46(91):76-9</ref> | ||
*Management of ICP | *Management of [[elevated ICP|ICP]] | ||
**Head of bed to 30 degrees | **Head of bed to 30 degrees | ||
**Short-term use of hyperventilation | **Short-term use of hyperventilation | ||
**Hyperosmolar agents ([[Mannitol]], 3% saline) | **Hyperosmolar agents ([[Mannitol]], [[hypertonic saline|3% saline]]) | ||
*[[ | *[[Anticoagulant reversal|Reversal of anticoagulation]] | ||
*Treat and prevent hypotension and hypoxia | *Treat and prevent hypotension and hypoxia | ||
**Associated with significantly increased mortality<ref>Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A. and Foulkes, M.A. (1993) ‘THE ROLE OF SECONDARY BRAIN INJURY IN DETERMINING OUTCOME FROM SEVERE HEAD INJURY’, The Journal of Trauma: Injury, Infection, and Critical Care, 34(2), pp. 216–222.</ref> | **Associated with significantly increased mortality<ref>Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A. and Foulkes, M.A. (1993) ‘THE ROLE OF SECONDARY BRAIN INJURY IN DETERMINING OUTCOME FROM SEVERE HEAD INJURY’, The Journal of Trauma: Injury, Infection, and Critical Care, 34(2), pp. 216–222.</ref> | ||
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==Disposition== | ==Disposition== | ||
*Admission to | *Admission to neurosurgery or trauma surgery | ||
==See Also== | ==See Also== | ||
Latest revision as of 16:21, 3 October 2019
Background
- Can present as acute (<14 days) and chronic (>14 days)
- Both types are caused by sudden acceleration-deceleration of the brain with resultant shearing of the bridging veins.
- Blood pools between the dura mater and arachnoid
- Patients with extreme atrophy are at increased risk (elderly, alcoholics)
- Patients less than 2 years old are also at increased risk
- SDH are often associated with other brain injuries
Clinical Features
- Patients with acute SDH generally will present unconscious after a severe trauma
- Patients with chronic SDH generally present with altered mental status or vague complaints
- High index of suspicion warranted in the aforementioned groups of patients at increased risk with any history of head trauma regardless of severity
Differential Diagnosis
Intracranial Hemorrhage Types
- Intra-axial
- Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
- Traumatic intracerebral hemorrhage
- Extra-axial
- Epidural hemorrhage
- Subdural hemorrhage
- Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)
Evaluation
Workup
- Consider head CT (rule out intracranial hemorrhage)
- Use validated decision rule to determine need
- Avoid CT in patients with minor head injury who are at low risk based on validated decision rules.[1]
- Consider cervical and/or facial CT
- Noncontrast CT brain is the gold standard
- Acute SDH will show as a hyperdense (white) collection with a crescent-shaped appearance
- Chronic SDH will show as a hypodense (dark grey/black) collection in a crescent-shape
- Contrasted studies are useful in distinguishing acute, subacute, and chronic
Management
- See Head trauma (main)
- Emergent neurosurgical evacuation
- Management of ICP
- Reversal of anticoagulation
- Treat and prevent hypotension and hypoxia
- Associated with significantly increased mortality[4]
- Emergency Department Burr hole, if indicated
Disposition
- Admission to neurosurgery or trauma surgery
See Also
External Links
References
- ↑ Choosing wisely ACEP
- ↑ Bullock MR, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006; 58(3):S16-24
- ↑ Evans JA, et al. A simple tool to identify elderly patients with a surgically important acute subdural haematoma. Injury. 2015 Jan;46(91):76-9
- ↑ Chesnut, R.M., Marshall, L.F., Klauber, M.R., Blunt, B.A., Baldwin, N., Eisenberg, H.M., Jane, J.A., Marmarou, A. and Foulkes, M.A. (1993) ‘THE ROLE OF SECONDARY BRAIN INJURY IN DETERMINING OUTCOME FROM SEVERE HEAD INJURY’, The Journal of Trauma: Injury, Infection, and Critical Care, 34(2), pp. 216–222.